To evaluate whether age influences a change in the spasticity of the ankle plantar flexor after botulinum toxin type A (BTA) injection in children with spastic cerebral palsy (CP).
Sixteen children with spastic CP were enrolled in the study. Seven children (group 1) were under 5 years of age, and nine (group 2) were over 5 years of age. They all received BTA injection in the gastrocnemius muscle (GCM) under ultrasound guidance. Passive range of motion (PROM) of ankle dorsiflexion, Modified Ashworth Scale (MAS) of the ankle plantar flexor, Gross Motor Function Measure (GMFM) and median red pixel intensity (RPI) of the medial GCM on real-time sonoelastography were measured at baseline (pre-injection) and 1-, 3-, and 6-month post-injection.
In both groups, the mean PROM, MAS, and RPI were significantly improved after injection until 6-month post-injection. The change of PROM of ankle dorsiflexion in group 1 was significantly greater than that in group 2, until 6-month post-injection. The change in the MAS and GMFM between baseline and 6-month post-injection in group 1 was greater than that in group 2. The changes in the median RPI between baseline and 3- and 6-month post-injections were greater in group 1 than in group 2.
Our pilot study demonstrated the different changes in spasticity of the ankle plantar flexor after BTA injection based on age. Therefore, age may be considered when establishing a treatment plan using BTA injection for children with spastic CP.
Citations
Birth brachial plexus palsy (BBPP) is usually caused by plexus traction during difficult delivery. Although the possibility of complete recovery is relatively high, 5% to 25% of BBPP cases result in prolonged and persistent disability. In particular, muscle imbalance and co-contraction around the shoulder and elbow cause abnormal motor performance, osseous deformities, and joint contracture. Physical and occupational therapies have most commonly been used, but these conventional therapeutic strategies have often been inadequate, in managing the residual muscle imbalance and muscle co-contraction. Therefore, we attempted to improve the functional movements, by using botulinum toxin type A, to reduce the abnormal co-contraction of the antagonist muscles.
Citations
To evaluate the short-term clinical effects of the intra-articular injection of botulinum toxin type A (BoNT-A) for the treatment of adhesive capsulitis.
A prospective, controlled trial compared the effects of intra-articular BoNT-A (Dysport; 200 IU, n=15) with the steroid triamcinolone acetate (TA; 20 mg, n=13) in patients suffering from adhesive capsulitis of the shoulder. All patients were evaluated using a Numeric Rating Scale (NRS) of the pain intensity and a measurement of the range of motion (ROM) at baseline (before treatment) and at 2, 4, and 8 weeks post-treatment.
The NRS at 2 weeks (BoNT-A vs. TA; 5.0 vs. 5.2), 4 weeks (4.1 vs. 4.9) and 8 weeks (3.8 vs. 4.6) of both treatment groups were significantly lower than that measured at baseline (7.4 vs. 7.6). The ROM of patients' shoulders increased significantly from baseline in both treatment groups. There was no significant difference in the NRS of pain intensity or the ROM between the two groups. Reduction in the pain intensity score was maintained for 8 weeks post-injection in both groups. There were no significant adverse events in either treatment group.
The results suggest that there are no significant short-term differences between the intra-articular injections of BoNT-A and TA. Although BoNT-A has a high cost, it may be used as a safe alternative of TA to avoid the steroid-induced side effects or as a second-line agent, for patients who have failed to respond to the current treatments.
Citations
To investigate the effect of botulinum toxin type A (BTXA) on drooling and the morphologic change of the salivary gland in patients with cerebral palsy.
Eight cerebral palsy patients suffering from severe drooling participated in this study. BTXA was injected into both submandibular and parotid glands under intravenous sedation and with ultrasound guidance (1 unit/gland/kg: maximum 100 units) in an outpatient or inpatient procedure. The severity of drooling was measured before injection and 3 weeks after injection using the Teacher Drooling Scale, the Drooling Score-severity, frequency and the Visual Analog Scale. To investigate the morphologic change of the salivary glands, the size of salivary glands were measured before injection and 3 weeks after injection using computed tomography of the neck. The measurement values were analyzed by Wilcoxon signed rank test.
Statistically significant improvements were shown in all three parameters for assessing the severity of drooling after BTXA injections (p<0.05). Size of the salivary glands were significantly decreased at 3 weeks after BTXA injection (p<0.05).
Salivary gland injection with BTXA could be a useful treatment method to reduce drooling in patients with cerebral palsy and decreased size of salivary glands may partially explain the mechanism.
Citations
To identify the effect of serial casting combined with Botulinum toxin type A (BTX-A) injection on spastic equinus foot.
Twenty-nine children with cerebral palsy who had equinus foot were recruited from the outpatient clinic of Rehabilitation Medicine. The children were divided into 2 groups, one of which received serial casting after BTX-A injection, and the other which only received BTX-A injection. Serial casting started 3 weeks after the BTX-A injection, and was changed weekly for 3 times. Spasticity of the ankle joint was evaluated using the modified Ashworth scale (MAS), and the modified Tardieu scale (MTS). Gait pattern was measured using the physician's rating scale (PRS).
The degree of ankle dorsiflexion and the MAS improved significantly until 12 weeks following the BTX-A injection in the serial casting group (p<0.001), while the BTX-A injection-only group improved until 6 weeks following injection (p<0.05). The combined group showed a significantly greater increase in the degree of dorsiflexion compared to the BTX-A injection-only group at post-injection weeks 6 and 12 (p<0.05). Three children (11.5%) suffered from foot ulcers as a complication caused by the serial casting.
Our study demonstrated that the effect of BTX-A injection with serial casting was superior and lasted longer than the effect of BTX-A injection only in patients with spastic equinus foot. We therefore recommend BTX-A injection with serial casting for the treatment of equinus foot. However, physicians must also consider the possible complications associated with serial casting.
Citations
Method Fifty patients were assigned at random to receive intra-articular shoulder injection. The treatment groups were divided into two groups: BoNT-A group, 200 IU of BoNT-A and 2 ml of normal saline; triamcinolone acetonide (TA) group, 20 mg of triamcinolone and 2 ml of 2% lidocaine. Uptake ratio of quantitative three phase bone scintigraphy (QTPBS) was calculated by dividing the radioactivity count on the affected side by that on the unaffected side. Shoulder pain was assessed by visual analogue scale (VAS) and neuropathic pain scale (NPS). Range of motion (ROM) of shoulder joint and functional independence measurement (FIM) of upper limb were evaluated. All of them were measured before injection, and 4 weeks after injection.
Results After 4 weeks, the uptake ratio of blood pool phase was significantly decreased in hands of BoNT-A group than TA group. VAS, ROM and upper extremity FIM was similarly improved in both groups. Pain intensity and cold pain of NPS were similarly decreased in both groups. Hot pain and dull pain of NPS decreased more significantly in BoNT-A group than TA group.
Conclusion In the short-term, intra-articular BoNT-A shoulder injection maybe has the therapeutic effect on acute CRPS I related stroke. And the uptake ratio of blood pool phase of the hand of QTPBS may be useful to assess the therapeutic effect of CRPS after acute stroke.
Objective: Botulinum toxin works at the neuromuscular junction by inhibiting the release of acetylcholine from the presynaptic membrane. It has been indicated for limb spasticity in patients with upper motor neuron lesions. The paralytic effect of this toxin usually lasts for 3 to 4 months, and repeated injections are needed to maintain the effect. This study was performed to investigate whether electrical stimulation can prolong the paralytic effect induced by botulinum toxin type A.
Method: Ninety male Sprague-Dawley rats, 30 for control and 60 for experimental, were studied. Botulinum toxin type A (DysportⰒ) was injected into the gastrocnemius muscle in the experimental groups (10 units for group 1 and 5 units for group 2), and normal saline 0.05 ml was injected into the same muscle in the control group. Thirty minutes of electrical stimulation was applied to the injected muscle with surface-stimulating electrodes. The stimulation was given once a day for 3 times in subgroup E1 and once every other day for 6 times in subgroup E2. No electrical stimulation was applied to subgroup N. Amplitudes of action potentials were measured serially on the injected muscles. At the third week, hematoxylin-eosin stained sections and synaptophysin immunohistochemical stained sections were examined.
Results: 1) At the second week after the toxin injection, amplitudes of action potentials maximally declined to 2.1∼3.7% in group 1 and to 4.0∼5.3% in group 2, compared to the initial amplitude. The amplitudes were beginning to recover from the third week. 2) Electrically stimulated groups demonstrated significantly more depressed amplitudes than non-stimulated group N. These effects lasted till week 2∼4. 3) Hematoxylin-eosin staining for muscle sections showed degenerative changes of muscle fibers. Synaptophysin immunoreactivity in the muscle demonstrated multiple synaptophysin-positive areas in a muscle fiber of the toxin injected muscle.
Conclusion: Transient electrical stimulation to the botulinum toxin injected muscles seems to enhance the paralytic effects of the toxin.
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